Prevalence of Liver Steatosis and Fibrosis and the Diagnostic Accuracy of Ultrasound in Bariatric Surgery Patients

Background  

Liver steatosis can progress to fibrosis, cirrhosis, and eventually to end-stage liver disease and hepatocellular carcinoma. We thus determined the prevalence of liver steatosis and fibrosis in patients undergoing bariatric surgery using liver biopsy. We also determined the suitability of ultrasound for diagnosis of liver steatosis with and without simultaneously considering patient characteristics.     

Effect of Bariatric Surgery on Liver Fibrosis

Background

Although bariatric surgery has been shown to improve hepatic steatosis in morbidly obese patients, the effect of weight loss on hepatic fibrosis has not been determined. Since the prognosis of patients with nonalcoholic fatty liver disease is closely related to the development of hepatic fibrosis, it is important to determine the hepatic histology of these patients after weight loss. We therefore evaluated the prevalence of hepatic fibrosis in morbidly obese patients undergoing bariatric surgery and assessed the correlation of histologic changes with weight loss.

Methods

We retrospectively evaluated 78 morbidly obese patients who underwent gastric bypass. Liver biopsies were taken during surgery and after weight loss, and the correlations between histologic findings and hepatic fibrosis were determined.

Results

Of the 78 patients, 35 (44.8%) had fibrosis at first biopsy, and 24 (30.8%) had hepatic fibrosis after weight loss, including 19 of the 35 patients (54.3%) with fibrosis at first biopsy and 5 of the 43 (11.6%) without hepatic fibrosis at first biopsy (P?=?0.027).

Conclusions

Weight loss in morbidly obese patients was associated with a reduction in the prevalence of hepatic fibrosis.     

The Correlation Between Obesity-Related Diseases and Non-alcoholic Fatty Liver Disease in Women in the Pre-operative Evaluation for Bariatric Surgery Assessed by Transient Hepatic Elastography

Background

Non-alcoholic fatty liver disease (NAFLD) is a common, severe disease in obese patients. However, NAFLD is usually underestimated by ultrasonography. Liver biopsy is not routinely done in bariatric surgery or during the follow-up. This study therefore examined the correlation between metabolic syndrome and NAFLD in morbidly obese patients based on an assessment using transient hepatic elastography (THE).

Material and Methods

This study involved 50 female patients in the pre-operative phase for bariatric surgery. Before surgery, we collected clinical, laboratory, and anthropometric variables. THE measurements were obtained using a FibroScan® device (Echosens, Paris, France), and steatosis was quantified using Controlled Attenuation Parameter software (CAP). Statistical analyses were done using linear correlation and the Kruskal-Wallis test.

Results

The mean of THE and CAP values were 7.56?±?4.78 kPa and 279.94?±?45.69 dB/m, respectively, and there was a significant linear correlation between the two measurements (r?=?0.651; p?<?0.001). The numbers of metabolic syndrome parameters did not influence the THE (p?=?0.436) or CAP (p?=?0.422) values. HbA1c and HOMA-IR showed a strong linear correlation with CAP (r?=?0.643, p?=?0.013 and r?=?0.668, p?=?0.009, respectively) and a tendency to some linear correlation with THE (r?=?0.500, p?=?0.05 and r?=?0.500, p?=?0.002, respectively).

Conclusion

Morbidly obese women submitted to FibroScan® presented a high prevalence of severe steatosis and advanced fibrosis in our sample. Insulin resistance parameters were correlated with steatosis, but less with fibrosis.

     

Improving the Diagnostic Accuracy of Hiatal Hernia in Patients Undergoing Bariatric Surgery

Background

Surgical correction of hiatal hernia (HH) during bariatric surgery has been found to improve patient outcomes and decrease reoperation rate. Although barium esophagram is more sensitive than endoscopy for detection of HH, accurate preoperative diagnosis remains a challenge. The aim of this study is to determine whether diagnostic accuracy improves by utilizing right anterior oblique (RAO) esophagram technique instead of the commonly used upright technique when comparing to the gold standard of intraoperative detection.

Methods

All patients undergoing bariatric surgery were prospectively evaluated for HH by barium esophagram. After the first 69 patients, the technique was changed from upright to RAO. Hiatal hernia was assessed intraoperatively by laxity of the phrenoesophageal ligament and, if present, was repaired posteriorly. Two board-certified radiologists specializing in gastrointestinal radiology, who were blinded to the intraoperative results, retrospectively reviewed the esophagrams. Consensus reads were utilized for divergent opinions. Sensitivity and specificity were calculated for each technique.

Results

Between 2008 and 2010, a total of 388 patients underwent preoperative esophagrams (69 upright, 388 RAO). For upright esophagram, sensitivity was 50?% and specificity was 97?%. For RAO esophagram, sensitivity was 70?% and specificity was 77?%. RAO had a lower percentage of false negatives (11 vs. 21?%) than upright esophagram.

Conclusions

The use of RAO technique for preoperative esophagram is more sensitive for diagnosis of hiatal hernia than upright esophagram. If surgeons desire routine preoperative esophagram, RAO technique is the best.     

Psychological Characteristics of Morbidly Obese Candidates for Bariatric Surgery

Background  

Morbid obesity has multiple negative consequences for psychological health. These patients are described as depressed, anxious, and impulsive, with low self-esteem and impaired quality of life. The severity of these psychological disorders has been related to the degree of obesity. The aim of this study was to analyze the psychopathological characteristics of obese candidates for bariatric surgery, determining differences and similarities in general and specific psychopathologic symptoms among patients with different degrees of obesity and normal-weight individuals.     

The Objective of Psychological Evaluation in the Process of Qualifying Candidates for Bariatric Surgery

Psychosocial and behavioral variables play an important role in both the development and treatment of obesity. Therefore, in the process of qualifying the patient for bariatric surgery, it is necessary to professionally evaluate his/her psychological state. Such evaluation is very helpful in the identification of factors potentially disturbing the effectiveness of the treatment. Clinical interviews with a group of 80 patients were conducted by a psychologist in the pre- and post-surgical period. The qualitative analysis of the interviews led to the identification of the major elements which should become the object of psychological evaluation in the process of qualifying patients for bariatric surgery. Conducting a clinical interview comprising these elements allows one to evaluate their potential influence on the process of surgical treatment of obesity and to provide optimal psychological support for the patient before and after the surgery.     

High Incidence of Appendix Carcinoid Tumors Among Candidates for Bariatric Surgery: Diagnostic and Therapeutic Implications

Although the appendix has been recognized as a preferential site for carcinoid tumors in obese patients, no definitive guidelines are so far available regarding the management of these patients when candidates for bariatric surgery. This study was designed to fill that gap. Between 2000-2008, 558 patients underwent bariatric procedures. Appendectomy was routinely performed in 477 cases. Their charts were retrospectively retrieved and histopathology responses on surgical specimens were recorded. We aimed to assess: incidence of appendix carcinoid tumors (ACTs) and any possible risk-factor; modality of diagnosis (pre-, intra- or post-operatively); impact on the planned bariatric procedure; treatment reserved to such cases. Typical ACTs were diagnosed in 7 patients (1.4%) (median age: 33 years; median BMI: 49 kg/m2; males/females: 1/6). Four were diagnosed intra-operatively. Because of dimensions (<2 cm) and absence of mesoappendiceal or serosal involvement, simple appendectomy was performed during bariatric procedure, as planned. Three were diagnosed post-operatively (all <2 cm). In 1 case right hemicolectomy was performed 1 month later due to mesoappendiceal involvement. No appendectomy-related complication was encountered. All patients remained tumor-free during follow-up (mean: 64 months; range, 25-92). Young age, female sex, high BMI and diabetes mellitus resulted significantly associated with ACT. Our study sustains routine appendectomy or at least careful investigation of the appendix during bariatric surgery. For tumors <2 cm without mesoappendiceal or serosal involvement, simple appendectomy proved sufficient. Bariatric surgery did not have a negative effect on the treatment of malignancies that are discovered intra- or post-operatively.     

Revisiting the Revised Master Questionnaire for the Psychological Evaluation of Bariatric Surgery Candidates

Background  

This study aims to evaluate the Revised Master Questionnaire (MQR), a measure of cognitive and behavioral difficulties related to weight management, for use in bariatric surgery evaluations. The MQR’s five domains include stimulus control, hopelessness, motivation, physical attribution, and energy balance knowledge, all of which are relevant to bariatric surgery evaluation.     

Psychometric Evaluation of Disordered Eating Measures in Bariatric Surgery Candidates

Introduction

Assessment of disordered eating is common in bariatric surgery candidates, yet psychometric properties of disordered eating measures in this population are largely unknown.

Methods

Measures were completed by 405 adult bariatric surgery candidates at pre-surgical consultation. Fit of the original scale structures was tested using confirmatory factor analysis (CFA) and alternative factor solutions were generated using exploratory factor analysis (EFA). Reliability (internal consistency), construct validity (convergent and divergent) and criterion validity (with the EDE as criterion) were assessed.

Materials

The measures prioritised for evaluation are the following: Eating Disorder Examination Questionnaire (EDE-Q; n?=?405), Three-Factor Eating Questionnaire (TFEQ; n?=?405), Questionnaire of Eating and Weight Patterns Revised (QEWP-R; n?=?204), Clinical Impairment Assessment (CIA; n?=?204) and the Eating Disorder Examination clinical interview (EDE; n?=?131).

Results

CFA revealed adequate fit for only the CIA in its current form (CFI?=?0.925, RMSEA?=?0.096). EFA produced revised scales with improved reliability for the EDE, EDE-Q and TFEQ. Reliability of revised subscales was improved (original scales α?=?0.43–0.82; revised scales α?=?0.67–0.93). Correlational analyses of the CIA and revised versions of remaining scales with measures of psychological wellbeing and impairment revealed adequate convergent validity. All measures differentiated an EDE-classified disordered eating group from a non-disordered eating group (criterion validity). Diagnostic concordance between the EDE, EDE-Q and QEWP-R was low, and identification of disordered eating behaviours was inconsistent across measures.

Conclusions

Findings highlight the limitations of existing disordered eating questionnaires in bariatric surgery candidates. Results suggest revised assessments are required to overcome these limitations and ensure that measures informing clinical recommendations regarding patient care are reliable and valid.

     

Pregnant Women After Bariatric Surgery: Diagnostic Accuracy of Magnetic Resonance Imaging for Small Bowel Obstruction

Obesity Surgery - Small bowel obstruction (SBO) is a late complication of Roux-en-Y gastric bypass (RYGB). In non-pregnant patients, computed tomography (CT) is the first choice of imaging. During...     

Objective Assessment of Time Spent Being Sedentary in Bariatric Surgery Candidates

Background  

Bariatric surgery candidates spend very little time in moderate-to-vigorous intensity physical activity (≥3 metabolic equivalents [METs]). This study examined (1) how much of their remaining time is spent in sedentary behaviors (SB < 1.5 METs) compared to light-intensity activities (1.5–2.9 METs) and (2) whether sedentary time varies by BMI.     

Limitations of the Millon Behavioral Medicine Diagnostic (MBMD) with Bariatric Surgical Candidates

Background  In this paper, we critique the Millon Behavioral Medicine Diagnostic’s (MBMD) psychometric characteristics for use with bariatric surgery patients. Methods  The reliability data presented by the test authors in their manual were examined. Results  The results found 16 of 32 scales of have internal consistency reliability coefficients that do not meet minimal standards for use with bariatric populations. Of the remaining 16 scales, 13 do not have any compelling evidence that they are reliable. We suggest that if a test is not psychometrically reliable then its validity is called into question. Based on these data, 16 of the MBMD’s 32 scales have inadequate reliability and 13 are lacking evidence of reliability. We urge clinicians to carefully consider these findings and the implications for their work with bariatric surgery patients.     

Examining the Binge Eating Scale in Screening for Binge Eating Disorder in Bariatric Surgery Candidates

Background

This study assessed the utility of the Binge Eating Scale (BES) as a measure of binge eating disorder (BED) in a bariatric surgery-seeking population by (a) determining the optimal BES cut score for predicting BED, (b) calculating concordance statistics, and (c) determining the predictive value of each BES item.

Methods

Four hundred seventy-three patients presented for a psychological evaluation prior to Roux-en-Y gastric bypass surgery. The BES and the SCID semi-structured interview for BED were administered.

Results

Receiver operating characteristic curve analyses identified an optimal BES cut score of 17, which correctly classified 78% of patients with BED. A cut score of 27 improved this statistic, but significantly increased the number of false negatives, which is undesirable for a screening assessment. Discriminant function analyses revealed that nearly all BES items significantly predicted BED.

Conclusions

The BES is a valid screener of BED for patients seeking bariatric surgery; however, false positives can be expected. Administering the BES as part of a comprehensive psychological evaluation can help improve the assessment and treatment of patients presenting for bariatric surgery.     

A Novel Technique for Liver Retraction in Laparoscopic Bariatric Surgery

During bariatric surgery in morbidly obese patients, the surgeon’s operative view is often obscured by the hypertrophic fatty left lobe of the liver. The use of a conventional liver retractor mandates an additional subxiphoid wound, resulting in pain and scar formation, in addition to the risk of iatrogenic liver injury during retractor insertion. To overcome these limitations, we developed a simple, rapid, and safe technique for liver retraction—V-shaped liver suspension technique (V-LIST)—by using a Penrose drain and laparoscopic stapler. A silicone Penrose drain was inserted into the peritoneal cavity and stapled to the pars condensa of the lesser omentum and parietal peritoneum using a laparoscopic stapler. The left lobe of the liver was retracted by the V-shaped suspension. At the end of the surgery, the drain could be easily removed. In October 2009–February 2010, 14 patients underwent liver retraction with the use of this technique. We performed 12 Roux-en-Y gastric bypasses and 2 sleeve gastrectomies. This series also included three cases of single incision transumbilical laparoscopic surgery. The mean time required to complete the liver retraction was 8 min 21 s (range, 2–18 min 40 s). Retraction was appropriate in all patients, without the need for additional retractors or conversion. There were no V-LIST-related perioperative complications. Our V-LIST technique using a Penrose drain is safe and simple. It has potential applications in single incision laparoscopic bariatric procedures.     

Health and Nutritional Status of Vegetarian Candidates for Bariatric Surgery and Practical Recommendations

Introduction

Data on vegetarianism and bariatric surgery (BS) are scarce. We herein describe the health and nutritional status of vegetarian patients who plan to undergo BS and propose combined recommendations for vegetarian patients who undergo BS, based on our clinical experience and current scientific literature in both nutrition fields.

Methods

Cross-sectional analysis of a prospectively maintained database of all primary laparoscopic sleeve gastrectomies (LSG) performed at a bariatric center of excellence between January 2014 and November 2016 was carried out querying patients who declared a vegetarian or vegan lifestyle before surgery. Preoperative data collected included demographics, anthropometrics, dietary patterns, supplementation use, physical activity, smoking habits, co-morbidities, and blood tests. Each vegetarian was matched to five different omnivores based on age, gender, and BMI.

Results

During the study period, 1470 patients underwent primary LSG surgery (63.7% females). Twenty-one declared a vegetarian or vegan lifestyle (1.4%) pre-surgery. Most were classified as lacto-ovo (57.1%) and were driven from ethical reasons (85.7%). No differences were found between vegetarian and omnivore LSG candidates regarding co-morbidities and nutritional deficiencies, except for lower prevalence of impaired fasting glucose (14.3 vs. 47.1%;P = 0.007), lower ferritin levels (54.3 ± 50.5 vs. 96.8 ± 121.8 ng/ml; P = 0.052) and higher transferrin levels (313.9 ± 42.7 vs. 278.4 ± 40.4 mg/dl; P = 0.009) among the vegetarian cohort. Preoperative use of vitamin B12 and iron supplementation was higher among vegetarian LSG candidates than their omnivore counterparts (57.1 vs. 6.7%;P < 0.001 and 23.8 vs. 6.7%; P = 0.015, respectively).

Conclusions

Vegetarians have comparable health status and nutritional deficiencies, lower iron stores, and higher supplementation use before surgery compared to omnivore LSG candidates.

     

Liver Decompensation after Bariatric Surgery in the Absence of Cirrhosis

Obesity Surgery - Metabolic dysfunction–associated fatty liver disease–related cirrhosis is possible at the time of bariatric surgery, complicated by further liver decompensation....     

Correlates of Body Image Dissatisfaction in Extremely Obese Female Bariatric Surgery Candidates

Background: This study investigated correlates of body image dissatisfaction in 131 extremely obese female bariatric surgery candidates. Methods: Female gastric bypass surgery candidates participating in a comprehensive psychiatric evaluation completed a battery of established self-report measures of body image and psychosocial functioning. Nine predictors of body image dissatisfaction were considered: body mass index (BMI), ethnicity, childhood onset of obesity, childhood teasing about weight, binge eating, depression, self-esteem, shame, and perfectionism. Results: Stepwise multiple regression analysis revealed that the nine variables jointly accounted for 48% of the variance; three variables, depression, self-esteem and perfectionism, made significant independent contributions. Conclusion: Our findings highlight the importance of adult psychological functioning (depression, self-esteem and perfectionism) for predicting body image dissatisfaction in extremely obese female bariatric surgery candidates.